Provider Demographics
NPI:1528231180
Name:ELLIS, LORRAINE A (MFT)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 PROFESSIONAL DR
Mailing Address - Street 2:SUITE # 100-F
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7781
Mailing Address - Country:US
Mailing Address - Phone:916-780-1144
Mailing Address - Fax:916-781-6974
Practice Address - Street 1:2330 PROFESSIONAL DR
Practice Address - Street 2:SUITE # 100-F
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7781
Practice Address - Country:US
Practice Address - Phone:916-780-1144
Practice Address - Fax:916-781-6974
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40970106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist